Infertility


Infertility or inability to have a baby is the problem faced by almost 30% of the married couples. The couple, not able to conceive within one year of unprotected intercourse should seek treatment for this problem. Couple may have to have their first baby (primary infertility) or couple may have one/many babies and afterwards they are having some problem to carry the next pregnancy (secondary infertility)


Causes:  
1. Abnormalities in hormones/abnormal egg formation
2. Abnormalities in fallopian tubes/blockage of the fallopian tubes
3. Abnormalities in the uterus/inner lining of uterus where baby/embryo is supposed to grow
4. Abnormalities in the mouth of uterus and lower genital tract
5. Abnormalities in semen/male genital tract


Evaluation and treatment of individual cause:

1. Abnormalities in hormones/abnormal egg formation & egg release
These ladies may have abnormal patterns of menstruation and many other problems related to their weight, skin, breasts etc. basically some hormones released from brain affects the egg formation and egg release directly (FSH, LH) and other hormones affect egg formation indirectly (thyroid hormones, TSH, Prolactin) Any abnormality in one or more hormones leads to defective egg formation & release can cause problems for fertility. We do certain tests to know hormonal status and treat patient accordingly. We usually do serial trans- vaginal USG (follicular study) to know the process of egg formation and to determine timing of egg release. During follicular study the lady has to undergo short sonography every alternate day in first half of her cycle.  Abnormal egg formation can be managed by some tablets or hormone injections so as to grow one or many eggs of good quality. For egg release we give certain injections to the patient when egg is matured and try for pregnancy after 36 hrs of the injection.

2. Abnormalities in fallopian tubes/blockage of the fallopian tubes: 
These patients have some abnormality in their fallopian tubes due to various diseases. Pelvic infections, Endometriosis, intra abdominal adhesions, Mucus plugs/debris inside the tube can produce abnormalities in the fallopian tubes like Hydrosalphinx (water collection in the tube), complete or incomplete blockage of the tube, bends and kinks of the tube. We diagnose these or related abnormalities by doing trans-vaginal USG, special X-ray called HSG. Once the tubal abnormality is diagnosed we can correct it by doing some endoscopic surgeries. 

3. Abnormalities in the uterus/inner lining of uterus where baby/embryo is supposed to grow
Some ladies may have abnormal uterus/cavity inside the uterus due to defective development of the organ. These are septum (curtain like structure) inside uterus, small cavity, T shapes cavity (normally uterine cavity is triangular) non-developed or incompletely developed uterus (bicornuate/unicornuate).These ladies may have problem to conceive or they may land up into repeated abortions if they conceive. Some infections, injury to uterine lining due to previous abortions may cause inner lining of uterus to stuck to each other, creates problem for pregnancy to grow there. We can pick up these abnormalities by typical history given by patient, doing sonography, X-ray HSG. Generally we correct the abnormalities by doing hysteroscopic (Telescope inserted inside uterus through its mouth-cervix) surgeries

4. Abnormalities in the mouth of uterus and lower genital tract
Sometimes vaginal development is defective in the form of septum (curtain) either horizontally or vertically, underdeveloped vaginal region may cause problem to conceive. Thorough & gentle internal examination, USG can diagnose the problem which can be corrected by small surgeries. Some infections in vagina, ulcers at the mouth of the uterus (erosions) etc may cause some problem for pregnancy and can be managed by antibiotic therapies. 

5. Abnormalities in semen/male genital tract:
In almost 30% of the infertile couple’s problems are in husbands. So it is very important to give due consideration to them. We generally evaluate husband factors at the same time we are treating wife. Basic test for evaluation is semen analysis. Abnormal sperm count & abnormal motility are two main things leading to infertility. we can start with some medicines to improve count/motility and / or we can do IUI (inserting good quality sperms directly inside uterus by plastic tube, so that sperms will reach to the egg faster and unites with it) or IVF (test tube baby) depending upon the situation and apart from that seminal infections (managed by simple antibiotics), varicocele (swelling of the blood vessels of the scrotum), hydrocele (water collection inside the scrotum) are surgically correctable abnormalities. If there is any problem for husband to have intercourse (erectile dysfunction, premature ejaculation) we can always take andrologist’s help to solve the problem or to choose alternative options.
When couple comes to us for treatment to have a baby, we generally evaluate both husband and wife in initial couple of cycles. After diagnosing the problem we start treatment. Some patients conceives in evaluation cycle itself and don’t need further treatment. 
When couple is taking treatment to have a baby, we would request the couple to be patient. Every cycle (every month) the chances of pregnancy are around 25-30%. So it will be a big mistake to expect results in few days/ a month. To take 100% chance of being pregnant, we advice treatment at least for 6 months, if you are not getting results we can reassess you and try in a better way.


Some common terms worth consideration:

1. Follicular study/Folliculometry:
follicles are fluid filled sacs containing eggs. Each follicle will contain one developing egg. We generally do follicular study to follow growth of the follicle. The ovaries are stimulated by tablets/injections and follicular study is started on day 7/earlier/later depending upon which medicines were given to grow the follicles. It is done by trans-vaginal ultrasound on alternate day, till follicles are mature.

2. IUI-Intra Uterine Insemination:
This the process by which washed /good quality and highly motile sperms are deposited directly inside the uterine cavity by using small plastic canulla. IUI is done after/around follicular rupture. In case of normal intercourse sperms are deposited at the vagina and cervix (mouth of uterus)by doing IUI as sperms are entering directly inside uterus chances of pregnancy are more.

3. AID- Artificial Insemination of Donor Sperms:
AID is done in couples with very less sperm count and motility or absent sperms in semen. In such cases in valid option for IVF (Test tube baby) the process is similar to IUI, but in AID instead of washed semen of husband, donor’s semen is injected inside the cavity of the uterus. We get the donor semen sample from sperm banks.

4. PCOD (Polycystic Ovarian Disease or Syndrome):
Normally only one egg is generated in each menstrual cycle. In PCOD due to some hormonal disturbances many eggs are generated in on menstrual cycle and these many eggs don’t get ruptured. As the egg is not ruptured it causes irregular periods/problem to get baby. The condition is treatable with good results. The treatment is by medicines or by laparoscopy.

5. IVF-In Vitro Fertilization (test tube baby):
In Vitro fertilization is almost last step in fertility treatment. It is done for various reasons like low sperm count/motility, absent/blocked tubes, previous IUI failures, unexplained infertility etc. IVF consists of mainly four parts: Stimulation of the ovaries to produce more that 3 good quality eggs, removal/collection of matured eggs by the process called ovum pick up, keeping eggs and sperms together so that they will unite, the formed embryos after the egg-sperm union are injected inside the cavity of uterus and medication for pregnancy support are given.